Hospitals see gradual Obamacare growth

It’s going to rain, not pour, newly insured patients for hospitals and clinics when benefits under Obamacare start Wednesday.

New insurance plans or Medicaid will kick in New Year’s Day for people who signed up under the Affordable Care Act, giving providers some of the newly covered patients they were promised when the health law was passed four years ago. But in most places, the influx is likely to be gradual — and there will still be millions of uninsured people walking through their doors in need of medical care.

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Much uncertainty remains for hospitals and clinics, which are getting new revenue from the bigger insured population while seeing some payments and subsidies shrink. But the changes may be less dramatic than feared — or hoped. Enrollment was slower than expected this fall, although it picked up in December, and coverage expansion was always viewed as a multiyear project.

The result may be fewer new patients showing up immediately and less severe crowding and physician shortages overall than some health industry analysts had expected.

Hospitals have been getting ready for several years for the new patient mix, with many reaching into communities to provide care beyond their emergency departments and inpatient beds.

“We’re not anticipating a bum rush to the doors of hundreds of newly insured patients,” said Kate Rose, senior director for public policy and government relations at Montefiore Medical Center in the Bronx. Still, the hospital has been preparing, tweaking its scheduling system to cut down wait time for appointments, for instance, and working on ways of getting people into the primary care and outpatient clinics.

“Is it anything that’s overwhelming? Not for us,” Rose said of the changes starting Jan. 1.

Although HealthCare.gov and many state exchange websites struggled through glitches during the first few months of Obamacare enrollment, 2.1 million Americans signed up for private health insurance in time for Jan 1 coverage, the administration said Tuesday. Nearly 4 million qualified for Medicaid and CHIP.

But the numbers are still just a fraction of the 263 million insured people health providers are already serving — and the millions of remaining uninsured whom they also treat.

Hospitals face a very different landscape in states that have expanded Medicaid compared with those that chose not to do so. The situation is likely to be subdued in places like Texas and Florida, which have no Medicaid expansion and where Obamacare enrollment has been low. Fewer than 19,000 people were found to be eligible for Medicaid in each of those two states through November, and even fewer people enrolled in private exchange plans. State figures for December haven’t all been released.

But providers in California and other expansion states could see many new patients.

“There is going to be a quick surge because there are so few providers willing to serve the Medicaid population,” said Dan Hawkins, a senior policy official and lobbyist for the National Association of Community Health Centers. “It is a concern but not a major one. I think it would have been much of a concern if more states have taken the Medicaid expansion.”

Most people — some of whom have been living without health coverage for years — won’t rush in to see a doctor on Jan. 1, providers predict. They expect the increase to spread out over several months as people schedule checkups and other appointments. And they expect most of the newly insured to seek doctor visits or outpatient care rather than require hospitalization.

“There probably will be an uptick, but not everybody that’s newly insured has pent-up demand,” said Jeff Goldman, vice president for coverage policy at the American Hospital Association. “Their sort of initial access to services will be spun out over time.”

Clinics and other providers who serve the low-income population will see more of the new traffic, since the majority of known enrollments have been in Medicaid. But again, that will depend on the state.

“Virginia has not been that successful enrolling people that we’re going to have an avalanche,” said Martha Wooten, executive director of Alexandria Neighborhood Health Services . Although the state hasn’t yet expanded Medicaid, its incoming Democratic governor may change that decision. Wooten said she expects newly covered people to make appointments, not just walk in demanding immediate care.

A state like Maryland — which has embraced Medicaid expansion — could see more enrollees, although its exchange has suffered severe glitches that have slowed enrollment.

David Tatro, chief operations officer at Mary’s Center, a federally qualified health center with clinics in Washington , and the Maryland suburbs, said that its centers are operating under capacity. “We built this infrastructure to take on more patients, but we’re not seeing that just yet,” he said.

Tatro said the clinics’ Affordable Care Act sign-up assisters have enrolled 150 people in Maryland and 100 in D.C. — far fewer than the numbers that would overwhelm its providers.

In other places with already-extensive Medicaid programs, the changes may be milder.

“I can’t say that we’re preparing for a Jan. 1 blitz or anything,” said Alicia Wilson, executive director of La Clinica Del Pueblo, also a federally qualified health center in the District.

Wilson said that La Clinica is only anticipating a small drop in its number of uninsured patients. Currently, 40 percent are uninsured, and Wilson expects that figure to fall only a little to 37 percent in 2014 because Obamacare enrollment has been slow.

Vincent Keane, president of Unity Health Care in D.C., echoed Wilson’s comments. “We’re hoping for an increase. To the extent that it will be an overwhelming increase, probably not,” he said.

The good news for providers is that more of the patients who walk through their doors will have a way to pay for the care they receive. And for those who still haven’t enrolled in coverage, providers are putting more enrollment helpers on the job to make sure everyone who can still get signed up, does so.

Community clinics have doubled their enrollment workers, Hawkins said. Hospitals also said they’ve put more helpers at the wheel. They can help sign up people for Medicaid, which has a “presumptive” eligibility that gives hospitals more certainty that they’ll be reimbursed for services given to a patient immediately. (The sign-up teams can also help patients enroll in exchange health plans through March 31, but it takes a few weeks for coverage to kick in.)

The new Medicaid eligibility rules rely on a preliminary assessment, a process that used to apply only to pregnant women and children from low-income households. Providers will still get reimbursed for care they provided, even if the patient was later found to be ineligible. Under the narrower rules in effect before the health law, only emergency services would be reimbursed.

Besides being disproportionately low-income, the newly insured patients could also skew older and sicker than originally expected because of the early-on difficulties with signing up, said Nancy Chockley, president of the National Institute for Health Care Management. Signing up on HealthCare.gov often required multiple tries in October and November.

“Who’s motivated to work through all the enrollment hassles?” Chockley said. “The greater the need you have to secure health care insurance, the more you’re going to push through.”